The US Department of Health and Human Services (HHS) has announced the inflation-adjusted out-of-pocket (OOP) limits that will apply to non-grandfathered plans for plan years beginning in 2019. The OOP limit includes the plan’s deductible and cost-sharing amounts for benefits that are considered essential health benefits (EHB) under the Affordable Care Act (ACA).
Self-insured plans and large-group insured plans are not required to cover all EHBs (although small-group insured plans are), but to the extent they cover an EHB, they may not impose annual or lifetime dollar limits on the benefit. Additionally, OOP expenses for in-network EHBs must accumulate against the maximum OOP limit.
So, what are these EHBs? The ACA lists broad categories of essential health benefits (e.g., emergency care, prescription drugs, mental health and substance abuse treatments, preventive care, maternity and newborn care). Each state must designate a “benchmark plan,” with benefits included in that plan being the EHBs that must be covered under individual and small-group insurance policies regulated by that state. In contrast, self-funded and large-group insured employer plans may choose any state’s definition of benchmark plan for purposes of complying with the annual and lifetime dollar limits and OOP provisions.
Non-grandfathered plans must apply an embedded OOP limit for everyone enrolled in coverage other than self-only coverage. This requires each enrollee to have his or her own individual OOP limit on essential health benefits that is no higher than the maximum self-only OOP limit.
A plan would violate the ACA maximum OOP limit provision during its 2019 plan year unless it applied an OOP limit no higher than $7,900 to each individual enrolled as part of a family and, in addition, applied an overall OOP limit to the family no higher than $15,800.